Affiliation:
1. Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY
Abstract
Background: Clinical guidelines are defined as systematically developed statements
to assist practitioner and patient decisions about appropriate health care for specific
clinical circumstances. The clinical guideline industry has been erupting even faster
than innovation in health care, constantly adding unhealthy perspectives with broad
and complex mandates to health care interventions. Clinical guidelines are based on
evidence-based medicine (EBM) and comparative effectiveness research (CER).
Multiple issues related to the development of clinical guidelines are based on conflicts of
interest, controversies, and limitations of the guideline process. Recently, the American
Pain Society (APS) developed and published multiple guidelines in managing low back
pain resulting in multiple publications. However, these guidelines have been questioned
regarding their development process, their implementation, and their impact on various
specialties.
Objectives: To reassess the APS guidelines’ evidence synthesis for low back pain
diagnostic interventions using the same methodology utilized by the APS authors. The
interventions examined were diagnostic techniques for managing low back pain of facet
joint origin, discogenic origin, and sacroiliac joint origin.
Methods: A literature search by two authors was carried out utilizing appropriate
databases from 1966 through July 2008. Methodologic quality assessment was also
performed by at least 2 authors utilizing the same criteria applied in APS guidelines.
The guideline reassessment process included the evaluation of individual studies and
systematic reviews and the translation into practice recommendations.
Results: Our reassessment of Chou et al’s evaluation, utilizing Chou et al’s criteria,
showed good evidence for lumbar facet joint nerve blocks, fair evidence for lumbar
provocation discography, and fair to poor evidence for sacroiliac joint blocks to diagnose
sacroiliac joint pain. The reassessment illustrates that Chou et al have utilized multiple
studies inappropriately and have excluded appropriate studies. Also, Chou et al failed to
eliminate their bias in their study evaluations.
Conclusion: The reassessment, using appropriate methodology and including high
quality studies, shows evidence that differs from published APS guidelines.
Key words: Guidelines, evidence-based medicine, comparative effectiveness
research, systematic reviews, American Pain Society, interventional pain management,
interventional techniques, low back pain, diagnostic interventions, lumbar facet joint
nerve blocks, lumbar provocation discography, sacroiliac joint nerve blocks
Publisher
American Society of Interventional Pain Physicians
Subject
Anesthesiology and Pain Medicine
Cited by
14 articles.
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